Tag Archives: intramedullary fixation

Intramedullary Fixation of the Jones Fracture: A case report

by Al Kline, DPM1

The Foot and Ankle Online Journal 2 (6): 2

Intramedullary fixation of the Jones Fracture is described in this case report. Advantages of this procedure include percutaneous fixation of a Jones fracture without the need for traditional open reduction and a more rapid return to weightbearing and activity. The procedure is not technically difficult and provides excellent compression strength. This technique is indicated in stress fracture and/or fractures of a single cortex involving the fifth metatarsal.

Keywords: Intramedullary screw fixation, Jones fracture.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: May, 2009
Published: June, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0206.0002

Intramedullary fixation of the fifth metatarsal fracture or Jones fracture is not a new concept. This technique was first described by Kavanaugh, et al., in 1978. Initial techniques employed both the curved Leinbach screw and AO malleolar screw. Unfortunately, these stainless steel screws could break leading to incidence of failure. The procedure subsequently fell out of favor due to this complication. However, with the advent of stronger metals, this technique is once again introduced as a viable alternative to open, plate fixation of the Jones fracture. In April, 2007, the Carolina™ Jones-fracture system for foot and ankle surgery was launched by Wright Medical Group, Inc. Surgeons at Duke University and OrthoCarolina devised a system that uses high-strength screws specifically designed to treat the Jones fracture using intramedullary compression.

There are over 80,000 Jones fractures sustained annually in the United States. [1] It is now commonly reported that this fracture is under treated and sustains a high non-union rate. Some have reported up to 50% non-union rate. [2] Other reports have suggested a delayed-union rate as high as 66%. [3] The technique of intramedullary fixation is indicated for stress fracture of the fifth metatarsal with single cortex involvement and without comminution.

The advantage of this procedure is its simplicity and the ability to perform the procedure through a small percutaneous incision. This allows stable fixation of the fracture without a large incision and use of traditional plate fixation.

The intramedullary screw is ideal to promote stabilization of the fifth metatarsal fracture and allow the patient to return to activity sooner. Activity and weight bearing can be resumed as soon as 10 days following surgery.

Case Report

A 56 year-old female presents with pain and swelling to the lateral border of the foot. She reports slipping down a set of steps and sustaining a “burning pain” to the foot. She denies “twisting” or inverting the foot during injury. She continued to have pain and swelling following the injury and presented to our office. Radiographs confirmed a transverse stress fracture of the fifth metatarsal. The patient has a history of hypertension and hypercholesterolemia. She is a non-smoker and active. We scheduled the patient for intramedullary screw fixation. Because the patient was relatively sedentary and not athletic, we opted to fix the fracture with a 4.0 TiMax™ cannulated lag screw.

Surgical Technique

The patient was brought to the operating room and under IV sedation, a small skin block was performed along the base of the fifth metatarsal.

Using the Hologic®- InSight Fluoroscan mini C-arm, the fracture is identified. A small, percutaneous incision is made along the base of the fifth metatarsal. A guide wire can be used over the skin under fluoroscan to get a quick idea of the screw length needed for fixation. (Fig. 1).

Figure 1   The transverse stress fracture of the fifth metatarsal.  A percutaneous incision is made at the base of the fifth metatarsal under fluoroscan.

We used the TiMAX™ 4.0 cannulated lag screw. The lag design allows compression of the fracture site. It is important to place all the threads distal to the fracture site allowing for proximal lag compression when tightening the screw. By placing the run-out of the screw away from the fracture line, this helps to prevent screw fatigue or fracture. A washer is not required. The intramedullary guide wire is then placed across the fracture site and the proper length is determined. (Fig. 2)

Figure 2   The guide pin is placed across the fracture site to determine proper screw length.  Careful counter pressure is maintained at the fifth metatarsal head to prevent further distraction of the fracture site.

It is important to place some counter pressure along the long axis of the fifth metatarsal at the metatarsal head. This will prevent further distraction of the fracture site while drilling.

This is also important if the pilot hole is over-drilled. Soft tissue and tendon attachment is protected with a small drill sleeve and then the proper length screw is inserted. (Fig. 3).

Figure 3   The guide pin is then overdrilled and the screw is placed into the medullary canal.  The screw is tightened with compression of the transverse fracture site.

As the screw is tightened, you may place counter pressure along the long axis of the fifth ray. Using the fluoroscan, a noticeable ‘pinching’ of the fracture site will occur due to the compression force of the screw. The low-profile screw head may also be ‘buried’ into the hard, thick cortical portion of the styloid process ensuring to prevent screw head irritation. Once the screw is in place, it will provide significant stability to the fracture site and allow for earlier weight bearing and activity. (Fig. 4).

Figure 4   The threads of the lag screw are placed distal to the transverse fracture allowing for proper compression of the fracture.  The lag screw provides increased stability of the transverse fracture allowing for an earlier return to weight bearing and activity.

A single skin suture or ‘butterfly’ tape is then placed to close the small incision. The patient is then placed in a posterior splint and kept non-weight bearing for approximately 10-14 days. This can be followed by placing the patient in a CAM walking in a brace or simple post-surgical shoe. The screw may remain in the bone at the discretion of the patient and surgeon.

At 10 weeks post-op, the fracture site is well healed and the patient is walking without assistance or pain. (Figs. 5A and B)


Figure 5A and 5B   The fracture site 10 weeks after surgery.  The patient has been walking on the fracture site for 8 weeks after being maintained non-weight bearing in a posterior splint for the initial 2 weeks after surgery.  The fracture site is stable without signs of re-fracture or instability.


Intramedullary fixation of the Jones fracture is a simple and quick operative procedure. It allows for fracture stability without the need for a large, open reduction procedure. The procedure also allows for quicker weight bearing and return to activity without the risk of refracture.

The mechanism of injury is commonly described as stressed inversion and plantarflexion. In our case, however, the patient slipped and sustained an acute transverse stress fracture of the proximal diaphysis. In Kavanaugh et al., [3] original article, he also observed simple transverse diaphyseal stress fracture of the fifth metatarsal without a history of stress inversion or plantarflexion. [3]

Using force-platform analysis in eleven of twenty-three cases confirmed vertical and mediolateral forces concentrated over the fifth metatarsal causing stress diaphyseal fracture, not inversion stress.

Adduction of the forefoot is thought to potentiate stress leading to stress fracture. He concludes this to be the original Jones fracture as first described by Jones in 1902. He also observes that the stress fracture is difficult to treat and led to delayed union in eighteen of twenty-two patients treated conservatively (66.7%). Non-unions and delayed unions continue to be reported in cases of casting, even a stress fracture, since this study was first initiated. Refracture is also high in under treatment of this injury. Kavanaugh, et al., reported nine of twenty-two patients who sustained refracture after immobilization casting for an average of 23.3 weeks! [3]

Wukich, et al., recently reported a higher non-union and refracture rate with intramedullary screw fixation for the Jones fracture in a Division I athlete. This appeared to be due to using a smaller screw diameter. They propose using a larger diameter screw, up to 6.5 mm in diameter screw to fixate the Jones fracture in competitive athletes. [5]

The high incidence of non-union, delayed union and refracture justifies the need for earlier surgical intervention. Of course, patient needs and activity will be individualized. Although early weight bearing and activity can be achieved as early as 7 to 10 days after intramedullary stabilization of a Jones fracture, the individual weight and activity of the patient should be considered. In the athlete, this procedure allows for earlier activity and training. We advise a posterior splint, non-weight bearing for 2 weeks, with progression to weight bearing and a surgical shoe or CAM boot for an additional 2 to 4 weeks. The patient may then resume normal activity after 6 weeks.


1. Orthopedic Technology Review.: Product News: Jones-Fracture System.
2. Ortiguera CJ, Fischer DA: A review of the current treatment for fracture of the proximal fifth metatarsal first described by Jones. Orthopedic Technology Review 2 (4): 2000.
3. Kavanaugh JH, Brower D, Mann RV: The Jones Fracture Revisited. J Bone Joint Surg Am 60A: 776 – 782, 1978. [PDF]
4. Kline A: A review of the Jones fracture with simple classification for conservative versus surgical treatment. Podiatry Internet Journal, 1 (1): 10, 2006. [Online]
5. Wukich DK, Rhim B, Dial DM: Failed intramedullary screw fixation of a proximal fifth metatarsal fracture (Jones fracture) in a division I athlete: A case report. The Foot and Ankle Online Journal, 2 (6): 1, 2009. [Online]

Address correspondence to: Al Kline, DPM
3130 South Alameda, Corpus Christi, Texas 78404.
Email: al@kline.net

Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot and Ankle Online Journal, 2009

Failed Intramedullary Screw Fixation of a Proximal Fifth Metatarsal Fracture (Jones Fracture) in a Division I Athlete: A case report

by Dane K. Wukich, MD1 , Bora Rhim, DPM2, Dekarlos M. Dial, DPM3

The Foot and Ankle Online Journal 2 (6): 1

Intramedullary screw fixation of a Jones fracture is described in a basketball player (division I athlete). Early mobilization is the cornerstone to using intramedullary screw fixation in athletes. This case report describes the use of a smaller diameter screw to fixate a Jones fracture that failed. The authors have found that using a screw diameter similar to the diameter of the medullary canal may help to prevent screw failure.

Keywords: Intramedullary screw fixation, Jones fracture, screw failure.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: May, 2009
Published: June, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0206.0001

Jones fracture of the fifth metatarsal has been defined as an acute fracture occurring in the proximal portion of the fifth metatarsal base at the metaphyseal and diaphyseal junction in which the fracture can involve the 4th and 5th intermetatarsal joints. [1] Currently, there is no clear consensus on optimal treatment of acute Jones fractures in the athletic or the non-athletic population. There has been much debate in the treatment of proximal 5th metatarsal fractures since described by Sir Robert Jones in 1902. [2] The treatment of Jones fractures continues to remain controversial and challenging. [3]

Optimal screw selection for operative treatment in competitive athletes with 5th metatarsal Jones fracture has not been determined. Cannulated screw fixation has been a popular method of fixation and has gained wide acceptance. Due to increased failure rates in elite athletes from refracture, delayed union, and non union, Wright, et al., recommended using a larger solid screw in competitive athletes to counter the higher amount of torsional stress placed on the fracture site. [4] We present in this case report a Division I competitive basketball player who sustained a proximal 5th metatarsal fracture. His initial treatment involved open reduction and internal fixation (ORIF) with a small diameter intramedullary screw. The patient developed a nonunion and required autogenous bone grafting with larger diameter screw fixation. Selection of screw type and diameter deserves thorough consideration. The authors utilize large diameter solid screws that are compatible with the 5th metatarsal intramedullary canal diameter.

Case Report

A 21-year-old male collegiate basketball player presents with right foot pain. His symptoms began after jumping and landing awkwardly. He developed severe pain on the lateral border of his right foot. The pain is exacerbated with weightbearing and walking. The patient also reports a similar injury involving the right foot that resulted in a 5th metatarsal fracture 9 months prior.

The initial injury was treated operatively with intramedullary screw (4.0 mm cannulated) fixation. He is 6.9ft tall, weighs 113kg and in good health. The patient is not taking medications and denies any drug allergies. After the initial ORIF, he played in the 2004 – 2005 season. He reported intermittent pain of his right foot at the time.

The patient was evaluated after sustaining the second injury. He walked with an antalgic gait and had no deformity or atrophy.

The foot was tender to palpation at the base of the 5th metatarsal. Neurovascular status was intact with normal range of motion of his right foot and ankle.

Plain radiographs of the right foot revealed a nonunion of the proximal 5th metatarsal right foot. There was a 4.0 mm intramedullary cannulated screw within the 5th metatarsal. The screw was bent on both the anteroposterior and oblique radiographs. (Figs. 1A and B)


Figures 1A and 1B Anteroposterior and oblique radiographic views of the right foot demonstrating a bent 4.0 mm cannulated intramedullary screw. (A)  The oblique radiograph demonstrates the nonunion of left proximal 5th metatarsal fracture. (B)

The lateral preoperative views also show bending forces within the screw. (Fig. 2)

Figure 2  Pre-operative lateral radiograph right foot demonstrating nonunion of left 5th metatarsal Jones fracture and bending of the screw fixation.

A computed tomography (CT) scan was ordered and revealed a 50% incomplete union of a fifth metatarsal fracture consistent with nonunion. (Figs. 3A and B)


Figures 3A and 3B  CT scan of the right foot demonstrating non-union of right proximal 5th metatarsal (arrow).(A) Reformatted CT scan right foot demonstrating plantar lucency involving 50% of the proximal plantar cortex. (B)

The patient was then scheduled for hardware removal, bone grafting and screw exchange with a larger diameter intramedullary fixation screw. Before surgery, the patient was placed in a CAM walker with weight bearing to tolerance. In surgery, the 4.0mm cannulated intramedullary screw was identified and removed. The nonunion site was identified and curettaged. Autogenous bone graft was harvested from the ipsilateral calcaneus. A larger diameter 6.5 mm screw was placed in the intramedullary canal to achieve appropriate stabilization. He was placed in a compressive dressing immediately postoperatively and transferred into a below-the-knee fiberglass cast on the fifth post-operative day. Clinical union was achieved at 6-weeks and the patient was then asymptomatic. He was advanced to protected weight bearing in a CAM walker. (Figs. 4A and B)


Figure 4A and 4B  Post-operative anteroposterior radiograph left foot demonstrating radiographic union after revisional surgery with a 6.5 mm solid screw. (A)  Post-operative lateral radiograph demonstrating complete radiographic union using a 6.5mm solid screw along the plantar cortex with good alignment. (B)

At this time, stationary biking exercises were permitted. At 3-month follow-up, complete radiographic consolidation was noted at the fracture site. A CT scan was ordered and demonstrated complete radiographic healing of the fracture at 5 months. (Figs. 5A and B) The patient was permitted to return to competitive sports at 6 month follow-up.


Figure 5A and 5B  Post operative CT scan demonstrating stable 6.5 mm solid screw fixation with complete fracture union right 5th proximal metatarsal. (A)  Post operative reformatted sagittal CT scan. Note the stable fixation and complete fracture union. (B)


The type of screw fixation in the treatment of Jones fractures is controversial. Many surgeons support intramedullary screw fixation for Jones Fractures. [1,5,6,7,8,9] Kelly, et al., found that a 6.5 mm screw was superior to a 5.0 mm screw with respect to both pullout strength (in medullary canals greater than 5mm) and cantilever bending forces. [6] Excessive repetitive cantilever forces applied to a suboptimal smaller diameter screw may result in bending and ultimately screw failure resulting delayed or nonunion. For this reason, utilizing a large diameter screw in the larger athletic patient population has been advocated. [4,9,10] Vertullo, et al., encouraged utilizing an internal fixation device with the capability to resist torsion as well as bending. [11]

Refractures following initial intramedullary screw fixation of Jones fractures has been documented in athletes. Wright, et al., reported six refractures after complete radiographic and clinical union utilizing cannulated screw fixation of Jones fractures in athletes. [4]

The refractures were attributed to insufficient screw diameter in athletes with a larger body mass and failure to incorporate functional bracing during first season of play. Glasgow, et al., concluded that insufficient screw selection and vigorous return to activity appeared to correlate with failure and strongly discouraged intramedullary fixation with any device other than a 4.5 malleolar screw. [9]

Conversely, Porter, et al., reported on 23 consecutive athletes treated surgically with a 4.5 cannulated stainless steel screw for Jones fractures. [12] The authors reported 100% clinical healing, mean radiographic healing rate of 98.9% and a zero incidence of refracture in this series. Larson et al reported a 40% (6 of 15) failure rate of patients treated with initial intramedullary screw fixation. [10] There were a higher proportion of elite athletes (division I or professional level) among the failure group (83%) compared with those without complications (11%). None of the screws fractured in the failure group, but it was noted intraopratively that three were bent. There were no significant differences in age, sex, and screw diameter, use of bone graft or age of fracture between patients with failures and those without complications. In the current case report, suboptimal screw diameter was implicated as the precursor to refracture and failure.

Operative and non-operative treatment for Jones fractures has been described in the literature; however, in competitive athletic patients, operative treatment appears to be more favorable. [13,14] Due to vascularity, muscle insertions, and motion related to the fifth metatarsal, O’Shea, et al., recommend that most Jones fractures be internally fixated for a more rapid return to function. [15] Early operative treatments of acute Jones fractures results in quicker times to union and return to sports compared with cast treatment. [5,13,15,16] Konkel, et al., recommended nonoperative treatment of fifth metatarsal fractures for patients in whom the time to full activities is not critical. [17]

The fifth metatarsal shaft bowing and intramedullary canal width deserve special attention. If unrecognized, variations in 5th metatarsal diaphyseal anatomy could lead to intraoperative morbidity. Ebraheim, et al., demonstrated that the intramedullary canal is bowed and the dorsoplantar diameter is more than 1mm narrower than the mediolateral diameter. [18]

Pre-operative lateral and oblique radiographs allow assessment of severe lateral bowing of the shaft. [3] We concur with Ebraheim, et al., in that the intramedullary canal assessment allows for precise and accurate screw placement.

When utilizing intramedullary screw fixation for Jones fractures, we interpose the screw over the metatarsal under fluoroscopy. This facilitates accurate intramedullary screw selection and avoids potential intraoperative fracture.

Zelko, et al., reported that athletes in sports such as football or soccer are often able to participate in sports while the fracture is healing and basketball players are most disabled and require surgical treatment. [19] Kavanaugh, et al., noted a predilection for failure of varsity basketball players treated non-operatively. [13] In theory, the repetitive jumping and running of basketball increases cantilever bending at the fracture site compromising union.

Pietropaoli, et el., conducted a biomechanical study demonstrating no biomechanical difference between a 4.5mm malleolar screw and a 4.5mm partially threaded cancellous cannulated screw. [20] The physiologic loading of bone may be greater in the high performance athlete with a larger body mass; making smaller screws vulnerable to bending. In the study by Wright, et al., all patients were athletes and returned to full-speed activity an average of 8.5 weeks post-fixation. [4] Speculation on the cause of re-fracture included early return to activity, insufficient screw diameter, use of cannulated screws, and large patient body mass as possible sources. This case report is consistent with Wright’s study and we believe larger diameter screws are required in patients with a larger body mass.

In conclusion, intramedullary screw fixation provides excellent stabilization in proximal 5th metatarsal fractures. The 5th metatarsal diaphyseal anatomy and patient body mass deserve thorough consideration in selecting a screw that affords adequate endosteal purchase and stability.


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20. Pietropaoli MP, Wnorowski DC, Wener FW, et al. Intramedullary screw fixation of Jones fractures: A biomechanical study. Foot Ankle Int 20 (9): 560 – 563, 1999.

Address correspondence to: Dekarlos M. Dial, DPM, Cornerstone Foot and Ankle Specialists, 1814 West Chester Drive, Suite 300, High Point, North Carolina 27262

Chief, Foot and Ankle Division, Department of Orthopaedic Surgery; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
3rd year resident, Department of Graduate Medical Education; University of Pittsburgh Medical Center Surgery, Pittsburgh, Pennsylvania.
Foot and Ankle Fellow, Department of Orthopaedic Surgery; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

© The Foot and Ankle Online Journal, 2009